Academic Medicine最新文献

{"title":"The Shadow Economy of Effort: Unintended Consequences of Pass/Fail Grading on Medical Students' Clinical Education and Patient Care Skills.","authors":"Eric Warm, David A Hirsh, Benjamin Kinnear, Henrike C Besche","doi":"10.1097/ACM.0000000000005973","DOIUrl":"10.1097/ACM.0000000000005973","url":null,"abstract":"<p><strong>Abstract: </strong>The shift to pass/fail grading in undergraduate medical education was designed to reduce medical students' stress. However, this change has given rise to a \"shadow economy of effort,\" as students move away from traditional didactic and clinical learning to engage in increasing numbers of research, volunteer, and work experiences to enhance their residency applications. These extracurricular efforts to secure a residency position are subphenomena of the hidden curriculum. Medical schools do not officially require all the activities students need to be most competitive for residency selection; therefore, students, as rational actors, participate in the activities they think will most help them succeed.Here, the authors frame residency application and selection as a complex adaptive system (CAS), which self-organizes without centralized control or hierarchical intent. Individuals in a CAS operate in environments marked by volatility, randomness, and uncertainty-all of which are abundant in the residency selection process. Outcomes in such systems, like the development of a shadow economy, are novel, emergent, and cannot always be anticipated. To address these challenges, the authors suggest the need for deep understanding of the system's elements, interrelationships, and dynamics, including feedback loops and emergent properties. Optimizing the results of a CAS requires incentivizing outcomes over activities, ensuring open information flow, and engaging in continuous monitoring and evaluation.The current pass/fail era and resultant shadow economy of effort risk creating a triple harm by devaluing clinical excellence, burning out medical students, and potentially producing superficial or, worse, inauthentic academic and community work. Medical educators must optimize residency application and selection for cooperative outcomes and design incentives to ensure the outputs of medical education align student, institutional, patient, and societal goals. Without a set of predictive \"answers,\" the authors suggest a process of determining actions to advance this ultimate aim and reduce harm.</p>","PeriodicalId":50929,"journal":{"name":"Academic Medicine","volume":" ","pages":"419-424"},"PeriodicalIF":5.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142958400","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"教育学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"\"Mission-Aligned Funds Flow\": Effect on Clinical Departments.","authors":"Satyan Lakshminrusimha, Susan Murin, Joseph M Galante, Zishan Mustafa, Noel Sousa, Stanley Chen, Debbie A Aizenberg, Elizabeth Morris, David A Lubarsky","doi":"10.1097/ACM.0000000000005909","DOIUrl":"10.1097/ACM.0000000000005909","url":null,"abstract":"<p><strong>Problem: </strong>Academic medical centers struggle with the high cost of care, reduced reimbursement, intense competition, and low profit margins. Many factors, including a high proportion of publicly insured patients, a model rewarding procedural specialties, and research and educational support burden, led to faculty salary inequities, physician disengagement, and difficulty recruiting.</p><p><strong>Approach: </strong>UC Davis Health implemented an aligned funds flow model in July 2021 to create a mission-aligned model in which all departments had financial margins to optimize recruitment, retention, research, and teaching.</p><p><strong>Outcomes: </strong>The 3-year experience (academic years 2021-2024) with this model at UC Davis Health was characterized by physician compensation, physician recruitment, and profit increases. Total collections for departments increased by 4% in the first year, 0.2% in the second year, and 11.3% in the third year of funds flow. Total productivity increased by 4.9% during the first year, 3.6% during the second year, and 8.4% during the third year. Salaries increased in all departmental categories in year 3. Productivity and collections per faculty member increased during the first year and were stable during the second and third years. Parity among procedural, primary care, and hospital-based service lines was improved because departmental revenue was agnostic to payer mix and hospital agreements were more formulaic. The hospital contribution to funds flow increased from $67 million in 2022 to $101 million in 2024.</p><p><strong>Next steps: </strong>Regular communication and transparency are critical to ongoing trust and success with implementation of sustaining funds flow. The new model resulted in improved physician compensation and increased hiring. However, the implementation of funds flow had a negative fiscal effect on the academic medical center, and sustainability may require fine-tuning to balance affordability. The authors plan to convert outpatient primary care to productivity-based models and decrease time-limited support for new faculty from 2 years to 1 year.</p>","PeriodicalId":50929,"journal":{"name":"Academic Medicine","volume":" ","pages":"433-437"},"PeriodicalIF":5.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11939085/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142559323","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"教育学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Commentary on \"Listen Through\" by Stephen Clare.","authors":"Stephen Clare","doi":"10.1097/01.ACM.0001110312.33100.dd","DOIUrl":"https://doi.org/10.1097/01.ACM.0001110312.33100.dd","url":null,"abstract":"","PeriodicalId":50929,"journal":{"name":"Academic Medicine","volume":"100 4","pages":"427"},"PeriodicalIF":5.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143712018","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"教育学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Unacknowledged Moral Rights of Authorship in Academic Medicine Presentations.","authors":"Sharon Feldman, Giuliana C Antolovich, Monica S Cooper","doi":"10.1097/ACM.0000000000005949","DOIUrl":"10.1097/ACM.0000000000005949","url":null,"abstract":"","PeriodicalId":50929,"journal":{"name":"Academic Medicine","volume":" ","pages":"407-408"},"PeriodicalIF":5.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142830789","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"教育学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Medical Education in the Context of War in Ukraine.","authors":"Bohdan O Koshak, Svitlana I Smiyan, Anastasia V Bilukha","doi":"10.1097/ACM.0000000000005956","DOIUrl":"10.1097/ACM.0000000000005956","url":null,"abstract":"","PeriodicalId":50929,"journal":{"name":"Academic Medicine","volume":" ","pages":"407"},"PeriodicalIF":5.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142848375","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"教育学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"How Does the Novice Become the Expert? An Instrumental Case Study of Procedural Educators.","authors":"Ilana Roberts Krumm, Adrienne Strait, Lekshmi Santhosh","doi":"10.1097/ACM.0000000000005917","DOIUrl":"https://doi.org/10.1097/ACM.0000000000005917","url":null,"abstract":"<p><strong>Purpose: </strong>The classic paradigm of procedural education in medical training has involved trainees learning and performing invasive bedside procedures and subsequently teaching these procedures to more junior trainees. Many existing resident-as-teacher curricula focus on cognitive domains; there has been a lack of literature examining the transition from learner to teacher in procedural education. This hypothesis-generating instrumental case study explored how expert procedural educators transitioned from novice procedural educators to experts.</p><p><strong>Method: </strong>A constructivist approach with semistructured interviews was used to explore the individual narratives and experiences of faculty of the Hospitalist Procedure Service at the University of California San Francisco as they reflected on their journey from learners to teachers, focusing on the faculty of the hospitalist procedure team at the University of California San Francisco. All 12 Hospitalist Procedure Service faculty members received invitations to be interviewed, and 9 agreed to participate. Interviews were conducted between July and October 2023.</p><p><strong>Results: </strong>The 9 interviews created a rich and complex picture of the individual experiences and perceptions of procedural teaching. The faculty members varied in experience, ranging from 2 years on the procedure service faculty to more than 15 years of experience. Four main themes emerged from the interviews: methods for building teaching skills, tools that facilitate further educator growth, essential behaviors of effective educators, and common challenges. Inductive thematic analysis revealed trial and error as a major means of building procedural pedagogy and the use of precise communication as a crucial skill to manage learner cognitive load and the emotional challenges associated with learning and teaching procedures.</p><p><strong>Conclusions: </strong>The use of precise communication as a tool for both educator and learner to navigate the complexities of procedural teaching highlights the essential role of clear instruction and feedback in the learning process.</p>","PeriodicalId":50929,"journal":{"name":"Academic Medicine","volume":"100 4","pages":"453-458"},"PeriodicalIF":5.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143712019","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"教育学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Typology for Rural Residency Training.","authors":"Randall Longenecker, Darin Bell, Davis G Patterson","doi":"10.1097/ACM.0000000000005932","DOIUrl":"https://doi.org/10.1097/ACM.0000000000005932","url":null,"abstract":"<p><p>Until rural track program definitions were recently established in regulation and accreditation,1 there was no widely accepted classification system for rural graduate medical education (GME), making it difficult to conduct educational research, compare published results, or navigate the maze of options available to residency applicants. This typology for rural residency training, refined in use by rural medical educators, student applicants, and researchers2,3 over the past 2 decades, addresses varying degrees of required rurally located training, rural focus, and rural graduate placement outcomes. Acknowledging the range and differences across rural and frontier communities, this typology considers to be rural a geographic location that is rural by any 2 of the more than 75 federal definitions that exist (e.g., Core-Based Statistical Areas, Rural-Urban Commuting Area codes). For 8 common federal definitions, see RHIhub's \"Am I Rural?\" Tool at https://www.ruralhealthinfo.org/am-i-rural.</p>","PeriodicalId":50929,"journal":{"name":"Academic Medicine","volume":"100 4","pages":"524"},"PeriodicalIF":5.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143712014","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"教育学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Training Health Professionals to Prevent Heat-Related Illness at Work.","authors":"Eric Persaud","doi":"10.1097/ACM.0000000000005947","DOIUrl":"10.1097/ACM.0000000000005947","url":null,"abstract":"","PeriodicalId":50929,"journal":{"name":"Academic Medicine","volume":" ","pages":"408-409"},"PeriodicalIF":5.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142774400","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"教育学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Financial Barriers to Rural Graduate Medical Education: Medicare Funding Methods for Sole Community and Medicare-Dependent Hospitals.","authors":"Mukesh Adhikari, Emily M Hawes, Jacob Rains, Christopher L Francazio, George M Holmes","doi":"10.1097/ACM.0000000000005948","DOIUrl":"10.1097/ACM.0000000000005948","url":null,"abstract":"<p><strong>Purpose: </strong>Policymakers are exploring options to address rural-urban physician maldistribution, including reducing rural residency training barriers. This study estimated Medicare graduate medical education (GME) reimbursement that sole community hospitals (SCHs) and Medicare-dependent hospitals (MDHs) are disqualified from receiving compared with hospitals under the Prospective Payment System (PPS) and calculated the GME reimbursement per resident for MDHs and SCHs under different scenarios.</p><p><strong>Method: </strong>This simulation study used Healthcare Cost Report Information System data on hospitals that had been SCHs or MDHs between 2011 and 2021 and did not have any resident full-time equivalents (FTEs) in the most recent year. Reimbursements were calculated under the PPS and hospital-specific rate (HSR), assuming all other hospital financing elements remained unchanged, apart from adding resident FTEs.</p><p><strong>Results: </strong>A total of 242 hospitals were identified as current or recent SCHs or MDHs with an average daily census of 25 or more and no residents in their most recent cost reports; 139 (57.4%) were paid under the HSR. The median (interquartile range) reimbursement per resident was $179,442 ($153,078-$208,412) under PPS and $107,294 ($85,134-$128,259) under HSR, a difference of nearly $70,000 per resident. The median opportunity cost per FTE was approximately $73,000 for SCHs and approximately $65,000 for MDHs. No significant per-resident differences were observed in the GME payments based on program size. Due to higher GME payments from PPS vs HSR, the number of hospitals defaulting to HSR decreased, and by the end of the third year of the program, more than 10% hospitals switched from HSR to PPS.</p><p><strong>Conclusions: </strong>Under the current health care and GME reimbursement method, SCHs and MDHs face considerable financial barriers to launching or participating in GME programs. Policy adjustments to address this barrier may incentivize more rural facilities to launch or participate in GME, potentially mitigating the geographic maldistribution of physicians.</p>","PeriodicalId":50929,"journal":{"name":"Academic Medicine","volume":" ","pages":"490-496"},"PeriodicalIF":5.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142787739","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"教育学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Stimulating Medical Student Professional Identity Formation Through Mentored Longitudinal Partnerships With Patient Teachers.","authors":"Lydia Busey, Natalie May, James R Martindale, Elizabeth B Bradley, Margaret Plews-Ogan, Rachel H Kon","doi":"10.1097/ACM.0000000000005960","DOIUrl":"10.1097/ACM.0000000000005960","url":null,"abstract":"<p><strong>Problem: </strong>Longitudinal patient relationships can positively affect medical students' professional identity formation (PIF), understanding of illness, and socialization within medical practice, but a longitudinal integrated clerkship (LIC) model is not always feasible. The authors describe the novel Patient Student Partnership (PSP) program, which provides authentic roles for students in mentored longitudinal patient relationships while maintaining a traditional block clerkship model.</p><p><strong>Approach: </strong>The PSP program at the University of Virginia School of Medicine pairs all matriculating medical students with a patient living with chronic illness to follow across multiple health care settings until graduation. The 4-year required program is rooted in the conceptual frameworks of PIF, experiential learning, and communities of practice. This program evaluation used survey data collected from the first full cohort of students (Class of 2022) at 5 timepoints during the initial 4 years of implementation (2018-2022).</p><p><strong>Outcomes: </strong>At graduation, 152 students had completed the PSP program. Students' narrative responses on surveys indicated PSP participation helped them connect classroom learning to clinical practice, play meaningful roles in patient care, practice communication skills via electronic health records, and practice self-reflection about their future roles as physicians. On the survey administered as students approached graduation, 54/67 (80.6%) of responding students agreed or strongly agreed that the PSP program allowed them to observe the general trajectory of a patient's chronic illness and its impact on daily life.</p><p><strong>Next steps: </strong>This initial evaluation demonstrates the feasibility of integrating a mentored longitudinal experience into an existing block curriculum. Future study of PIF development occurring during PSP activities is needed to explore whether the PSP program stimulates PIF in ways similar to LICs. Additionally, the authors plan to address variability in engagement between medical students and their patient teachers through further student and faculty development regarding role clarification.</p>","PeriodicalId":50929,"journal":{"name":"Academic Medicine","volume":" ","pages":"428-432"},"PeriodicalIF":5.3,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142928444","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"教育学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}